MEDICARE: THE CHILD CENTER OF NY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	06308	NY

General Provider Information

NPI Number	:	1033579917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CHILD CENTER OF NY

Provider Business Mailing Address
First Line	:	1761 3 AVENUE APT 12F
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10029
Country	:	US
Telephone Number	:	718-297-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1761 3RD AVE APT 12F
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10029-6818
Country	:	US
Telephone Number	:	718-297-8000
Fax Number	:

Authorized Official
Title or Position	:	FAMILY THERAPIST
Name	:	MIOSOTTE CABAN
Credential	:	CASAC-T
Telephone Number	:	718-297-8000

Provider Enumeration Date	:	03/04/2016
Last Update Date	:	03/04/2016

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